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1Y,�ftw' <br /> !rW <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: - CL �C�,i :a 1. Chemicals Hazards U.3 ct sty <br /> Address: [] Carcinogens: <br /> ContactPerson: PhondNo. []Corrosives: <br /> Sweeps Number: [ ] Dusts: <br /> Proposed Date of investigation/inspection: Explosives: <br /> [] Flammables: <br /> 2. Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation ( ] UAR Investigation [ ] Metals: <br /> ( ] Tank Closure in Place [ ] Tank/Pipe Repair ( ] Oxidizers: <br /> [ ] Tank/Pipe Removal [ ] Re-excavation (]PCBs: <br /> [ j Installation of Borings/Mo toting Wells <br /> C:7 S"maP_1e__ cvu5 .1_7?�� PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE <br /> Tank No. Tank Capacity: EQUIPMENT <br /> Tank Contents: Tank Age: <br /> Other: 1. Monitoring Equipment: (note: Monitoring <br /> ,✓ instruments must be used for all operations <br /> 4. Type of Operation: 7 G�`Cr�� C unless appropriate rationale or restrictions are <br /> provided) <br /> 5. Release History: [ ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: ` YES ( ] NO [ ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES [ ] NO [ ] Photoionization Detector <br /> Background and description of any previous investigation? [] Organic Vapor Analyzer <br /> or incidence: C C, 0 ( ] Other, specify: <br /> l�� r .1I7r If monitoring instruments are not used, <br /> rationale or activity/areare/s/,trictions: <br /> 6. Potential Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> [ ] Heat or Cold Stress: oP (high ambient temp.) <br /> [ ] Noise Source: 2- Personal Protective Equipment <br /> [ ] Oxygen Deficiency: Level of Protection: [ ]A [ ]B [ ]C `'[ D <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) ( ] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: Safety glasses/goggles <br /> (fire, explosions, etc.) Steel toed/shank shoes or boots <br /> [ ] Confined Space entry: (explosions) [ ] FIame retardant coveralls <br /> [ ] Heavy equipment (physical injury & trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> ( ] Respirator, circle: APR or SC3A <br /> [ ] Other, specify��s .v A/P cartridge:m1__ Safety vest <br /> 7. Anticipated Biological H /'l,!(9'n.e, � [ ] Two-way communication <br /> [ ] Snakes [ ] Insects [ ] Rodents ( ] Poisonous Plants <br /> [ ] Other/Unknown (specify): (, '11sV1 TJ -�- r C PART IV <br /> -�d� u-"f Ce yct t tv C� , PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: , q& Date: <br /> l ) /,E a-a-, <br /> t D — Plan Approved by Date: <br /> E142 081 (2/7/92) <br />